The nutrition agenda in Bangladesh: ‘Too massive to handle’?

Analysing Nutrition Governance: Bangladesh Country Report Linnet Taylor¹ February 2012 http://www.ids.ac.uk/idsproject/analysing-nutrition-governance

¹ I acknowledge the contribution of Alamgir Kabir for country support and knowledge sharing Contents Abbreviations .................................................................................................................. 3 I. Introduction .................................................................................................................. 4 II. Evolution of nutrition indicators in Bangladesh ......................................................... 5 III. Evolution and impact of nutrition policies in Bangladesh ........................................ 6 IV. Analysis of nutrition governance dynamics .............................................................. 7 a) Intersectoral cooperation ......................................................................................... 7 i. Formal structures for cooperation ........................................................................ 7 ii. Donor intervention and incentives for collaboration ........................................... 8 iii. Targeting and monitoring .................................................................................. 9 iv. Perceptions of ‘nutrition’ .................................................................................... 9 v. Electoral incentives and nutrition ....................................................................... 10 b) Vertical articulation .................................................................................................. 11 i. Siloed service provision ...................................................................................... 11 ii. Local coordination; local disjunctures ............................................................... 12 iii. Political capture ............................................................................................... 13 iv. Political sustainability ....................................................................................... 13 c) Funding mechanisms .............................................................................................. 14 d) Other factors potentially influencing malnutrition .................................................. 15 V. Relevant findings and preliminary conclusions .......................................................... 17 a) Findings .................................................................................................................. 17 i. Converging perceptions, diverging responses ...................................................... 17 ii) The politics of nutrition: sectorally divided, vertically fragmented .................... 17 iii) Siloed finances reinforce fragmentation ............................................................ 18 b) Entry points for intervention .................................................................................. 18 i. Responsibility for coordination .......................................................................... 18 ii. Siloed funding further decreases incentives to cooperate .................................... 19 iii. Aligning nutrition with electoral interests and the public agenda ....................... 19 VI. Bibliography ............................................................................................................. 21 Appendix: list of interviewees ......................................................................................... 22

### Abbreviations

| Abbreviation | Description | |--------------|-------------| | AL | Awami League | | BINP | Bangladesh Integrated Nutrition Project | | BNNC | Bangladesh National Nutrition Council | | BNP | Bangladesh Nationalist Party | | DfID | UK Department for International Development | | DHS | Demographic and Health Surveys | | GDP | Gross domestic product | | GMP | Growth monitoring and promotion | | GoB | Government of Bangladesh | | ICDDR:B | International Centre for Diarrhoeal Disease Research, Bangladesh | | IPHN | Institute for Public Health and Nutrition | | M&E | Monitoring and Evaluation | | MDFM | Ministry of Food and Disaster Management | | MDG | Millennium Development Goal | | MoA | Ministry of Agriculture | | MoF | Ministry of Finance | | MoH | Ministry of Health | | MoWCA | Ministry of Women and Children Affairs | | NGO | Non-governmental organisation | | NNP | National Nutrition Project | | NPAN | National Plan of Action for Nutrition | | PRSP | Poverty Reduction Strategy Paper | | SUN | Scaling Up Nutrition | | SWAp | Sector Wide Approach | | UNDAF | United Nations Development Assistance Framework | | UNICEF | United Nations Children’s Fund | | USAID | United States Agency for International Development | | WB | World Bank | | WHO | World Health Organisation | I. Introduction

Bangladesh was one of the 36 countries with more than 20 per cent stunting rates on which the Lancet Nutrition Series focused its investigation of the effects of nutrition interventions (Bhutta et al 2008). In 2009, it was included in the WHO’s landscape analysis of nutrition governance, which judged it to be a country which had placed strong emphasis on nutrition in both its PRSP and UNDAF. The country reported strong Nutrition Governance indicators, and appeared to be on track toward reaching MDG1, according to WHO data (WHO 2009). Being ‘on track’ means that, using the ‘underweight’ measure, a country is showing a reduction of 2.6 pp per year in malnutrition according to UNICEF’s official tracking. However, as will be shown later, this judgement can be disputed in the case of Bangladesh.

Bangladesh presents a contradictory case study in terms of ‘nutrition governance’. Although it is judged strong by the WHO’s measures, which are multidimensional but based primarily on policy documents, closer study reveals that there are various problems involved in this governance, many of which form barriers to the clear communication of goals and targets, and to the effective interaction of government, donor and implementing bodies. This study aims to outline these problems, along with existing and potential solutions, and to offer broad conclusions as to which strategies appear to be strongest in creating good nutrition outcomes. The research was carried out during 2011 and involved both desk research, mainly of Bangladeshi government documents, and other grey literature. It also involved interviews conducted in Dhaka, during June 2011 (see table 1 in appendix), during which 25 people were interviewed from various organisations relating to the national nutrition strategy and its implementation.

Bangladesh’s system of nutrition governance has long been affected by competition between the two main political parties, the centre-right Bangladesh Nationalist Party (BNP) and the centre-left Awami League (AL). Political affiliation is important in determining how individuals engage with different approaches to nutrition, and changes in the ruling regime have created significant obstacles to nutrition policy and implementation, issues which are explored further in the following sections. Given this intense two-party competition, the sustainability of policy interest and interventions across changes in regime are one important question that this report aims to address.

This study is based on the hypothesis that in order to effectively combat malnutrition, 1) nutrition policy must be well aligned with the political motivations of government and non-government actors, and 2) multiple stakeholders must be coordinated around policymaking and implementation. It looks at three main dimensions of nutrition governance: intersectoral coordination on the part of government, donor and other high-level bodies; vertical coordination within the country’s nutrition policy and implementation systems, and the modes of funding that are negotiated through, and used to implement, interventions. It also looks at how monitoring and data systems may support or undermine these forms of coordination and organisation, and at the political sustainability of successful interventions or forms of coordination.

Finally, in order to take account of the bigger picture within which these policy concerns are situated, the study looks at the broader socioeconomic context in Bangladesh. It asks what other issues may be playing a role in nutrition outcomes, and how these may be relevant to the policy issues that are the focus of this research. The overall aim of this research is to contribute to DFID’s effort to help government officials and decision makers in priority countries to effectively tackle the problem of maternal and child malnutrition.

II. Evolution of nutrition indicators in Bangladesh

Bangladesh has made strong progress in reducing its under-5 mortality rate, which has shown a 50 per cent decrease since 1993 and earned the country special recognition at the Millennium Development Goals (MDGs) Summit in September 2010 in New York (Global Health Initiative 2011). However, the prevalence of malnutrition remains high, with nearly one in two children underweight in 2006 and one in three stunted.

Figure 1 below shows both the stunting and underweight rates for Bangladesh over the period 1996-2006. Stunting data was not collected before this period. The ‘underweight’ measure is included here because it is the main metric used by UNICEF (among others) to assess whether countries are on track for MDG1 in 2015. This underweight rate, however, shows a reduction of 1pp per year over the decade that DHS data has been collected, rather than the 2.6 required to be on track for MDG1. The data brings into question the WHO landscape analysis assessment that the country is on track, with ‘strong’ nutrition outcomes.

Figure 1. Bangladesh stunting and underweight prevalence, 1996-2006

Besides this underweight metric, this study is also interested in the stunting rate, also shown in figure 1. Stunting, though not yet the most commonly referenced category for judging malnutrition, shows height-for-weight and, because it is less responsive to immediate shortages or increases in caloric intake, represents a country’s longer-term malnutrition and development scenario (BDHS 2007:146). Since 2004 stunting among children has declined by eight percentage points, but there is some indication of an increase in wasting (BDHS 2007, not shown in fig. 1), from 15 to 17 per cent. The percentage of children underweight, which combines both of these measures, has decreased slightly from 43 to 41 per cent. As this report will demonstrate, within the Bangladeshi government and donor community there are disagreements about which data sources to use for malnutrition rates, and a lack of awareness of the advantages and drawbacks of the different surveys available. This may be partly related to a shift from the input targets used in the 1980s and 1990s to the MDG target used since then. Government interviewees showed little awareness or understanding of the different surveys available, instead preferring to refer to smaller-scale, non nationally representative surveys they had commissioned. There was a particular distrust of sampled surveys such as the Demographic and Health Survey (DHS), which were felt to be statistically flawed and unrepresentative. However, there was no real rationale for this distrust. This report uses DHS data partly because it is comparable across countries, but mainly because it is internationally regarded as the most reliable source on malnutrition rates and health outcomes generally in developing countries.

III. Evolution and impact of nutrition policies in Bangladesh

The evolution of Bangladesh’s nutrition policy has progressed from basic recognition of the right to food, through the formation of policy processes to operationalise this right, to a specific nutrition programme and finally to the mainstreaming of nutrition into sectoral portfolios. The 1972 constitution recognises the right of Bangladeshis to the basic necessities of life, including food. Bangladesh is also a signatory to two international covenants, the Declaration on the Right to Development (1986) and the International Covenant on Economic, Social and Cultural Rights (1998), the latter of which specifically lays out the right to adequate nutrition (Shahabuddin 2010).

The first large-scale policy intervention in nutrition in Bangladesh was the NPAN (National Plan of Action for Nutrition) which was formed by the Bangladesh National Nutrition Council (BNNC) during the 1980s and activated as the Bangladesh Integrated Nutrition Plan (BINP) from 1995-2002. Managed by the Ministry of Health and Family Welfare, and funded by the World Bank, this initial policy aimed to reduce the prevalence of severe underweight by 40 per cent, and moderate underweight by 25 per cent. It took an intersectoral and rights-based approach quoting the constitutional right to food, but was judged to be hampered by a lack of effective empowerment and political coordination on the part of its managing body, the BNNC (Mannan 2003). With the mandate but not the power to coordinate, the BNNC was not able to put in place the necessary implementation and monitoring and evaluation (M&E) guidelines. The government’s failure to empower the BNNC was accompanied by a failure to follow through on its budgetary commitment to nutrition: during the 1990s the country spent 0.03 per cent of GDP on nutrition compared to its commitment of 0.5 in the original NPAN. This also rated poorly against India’s 0.3 per cent and Sri Lanka’s 1 per cent.

This policy was followed during 2002-11 by the National Nutrition Programme (NNP), which evolved out of the BINP. This programme reached around 20 per cent of the population (UNICEF 2008), rising to around 30 per cent in 2009. It involved information, advice and counselling provided by volunteer Community Nutrition Promoters working in community nutrition centres, and focused on improving the nutritional status of children, adolescent girls and women. However, beyond this Behaviour Change Counselling (BCC) work, therapeutic malnutrition treatment was still lacking and the multi-sectoral approach was still not being implemented, leading UNICEF (ibid) to report that only 20 per cent of the country’s severely malnourished children could be managed within health facilities. In 2011 the NNP was disbanded, and the country began to implement a strategy of ‘mainstreaming’ nutrition services – the main thrust being through an expansion of community clinics run by the Ministry of Health, providing therapeutic services for the severely malnourished. Overall responsibility for coordinating nutrition interventions remains with the Ministry of Health. This was funded largely by a Sector-Wide Approach (SWAp) through the World Bank and 16 other donors. This is the third in a series of SWAps (1998-2003, 2003-2011, 2011-2016), which have coincided with the country’s series of 5-year development programmes. This report will look at the legacy of these different policy approaches and funding mechanisms, and attempt to gauge the chances of success for the new mainstreaming policy.

IV. Analysis of nutrition governance dynamics

a) Intersectoral cooperation

i. Formal structures for cooperation

During 2011 nutrition policy coordination and implementation underwent a shift from management by the Ministry of Health and Family Welfare (hereafter the MoH) under the NNP to becoming ‘mainstreamed’ throughout the various sectors involved in planning and implementing interventions. Formerly, the MoH’s coordination function resided in several bodies under the banner of the NNP, each incorporating actors with different levels of seniority. The Institute of Public Health and Nutrition (IPHN), the Bangladesh National Nutrition Council (BNNC), and the NNP coordinating committee were all nominally in charge of managing and coordinating intersectoral cooperation, although the consensus among those interviewed from these institutions was that they had lacked the authority to effectively coordinate between ministries, and especially with the powerful Ministry of Agriculture.

In mid-2011 nutrition became one of the health sector’s 32 operations plans, so that the MoH’s operational structure became charged with conducting both preventive tasks such as nutrition communications interventions, therapeutic work, namely treatment of severe malnutrition, and monitoring infants’ and children’s growth. Under this plan, funded by the World Bank’s 2012-16 SWAp, 7 per cent of the health budget is allocated to nutrition. Other interventions relevant to nutrition, ranging from food security and school feeding to sanitation, reside in the relevant ministries as shown in Figure 2 below. This multisectoral approach can be considered strong in that it aims to use ministries’ specialist expertise, but it is dependent on effective and powerful coordinating mechanisms to align activities and monitoring of results – something which this report will show has not been put in place.

Figure 2 shows the range of ministries involved in combating malnutrition, and the bodies which are supposed to coordinate their activities. The IPHN was the main advisory body to the now-disbanded NNP (the managing body for the nutrition policy), and under mainstreaming continues as the main point of contact between the MoH and other sectors working on nutrition activities. The BNNC, although it still nominally exists, has been effectively defunct since it was disempowered by a change of ruling party in the mid-1990s. This body was supposed to be a ministerial-level policy council for nutrition, in contrast to the IPHN which dealt with implementation. However, the BNNC, nominally chaired by the Prime Minister, was not a real focus of authority and therefore lacked the ability to convene its members, meeting only once during the three years previous to 2011. Interviewees voiced unease with the intersectoral character of nutrition programming, unsure of the extent to which the MoH was motivated to coordinate with other sectors, or to which it was empowered to do so. One described the MoH as ‘maintaining relationships but not actually coordinating’. According to high-level officials within the MoH, its brief was not to coordinate other ministries, but solely to perform ‘health-related nutrition’ interventions: therapeutic care for severe malnutrition, along with some micronutrient provision.

ii. Donor intervention and incentives for collaboration Although there is high accountability for coherent policy formation, this is largely to donors, in the form of the World Bank directly, since it is the largest direct funder of the health sector, and of the Development Partners’ group. There is low accountability for coherent implementation, however. This is due to two factors. First, interventions funded by bilateral donors are subject to demands for accountability to those donors’ citizens and, in the case of multilaterals, to stakeholders at international level, rather than to the Bangladeshi government or civil society. Second, this has created a set of monitoring and evaluation structures that focus on inputs rather than outcomes, with the main outcome measure being the DHS surveys conducted every five years. The second of these will be dealt with in the following section.

These conflicting demands for accountability lead to a situation where bodies such as the IPHN, which are designed to provide accurate information on activities and outcomes, are insufficiently empowered, but where donors can instead build in their own monitoring mechanisms at the programmatic level. Although interviewees from both the government and donor sides commented that the structures that should be providing fora for communication and coordination were weakened by high-level tensions between ministries, they acknowledged that donors did not play a strong role in demanding intersectoral coordination because they were focused on accountability at the level of programs, rather than for coherent structuring and coordination of nutrition interventions across sectors. There was strong evidence of donor-driven decision making on the part of the government, particularly with regard to the World Bank. Given its overall funding of the health sector, the World Bank is the largest donor by far in nutrition, and has both a clear advantage in terms of a direct channel to the GoB, and minimal incentives to collaborate and coordinate with other donors, particularly bilateral ones. One unexpected consequence of pooled donor funding was that the ‘performance based funding’ attached to these funds (see later section on financing) in which the WB is the largest donor, was instrumental in persuading the GoB to give up the NNP and move to a mainstreaming strategy for nutrition.

Overall, there appeared to be no penalties for the GoB for failing to coordinate intersectorally, but potentially strong financial and political penalties for failing to coordinate with donors, particularly those making the highest contributions. This lack of motivation for intersectoral coordination, however, also seemed to impact on donors’ ability to work intersectorally, and to feed back into the larger disjuncture between sectoral perceptions and programming on nutrition. Donors were incentivised by the lack of coherent structures at governmental level to keep their programmes parallel to those of the government rather than integrating them: this created a feedback loop of fragmentation in many areas of nutrition programming. One senior government official commented on this highly diverse landscape of programmes that ‘you can get anything funded, this is Bangladesh’.

The Bangladeshi situation demonstrates that there is no natural progression from nutrition policy and activities to accountability for outcomes on the part of donors or government. Once this process of developing independent programmes was established – a common feature of the aid-receiving countries covered in this research – there is very little incentive for donors to take on the added task of creating ways to be accountable to the national government or its citizens. Similarly, government becomes focused on the difficult job of coordinating and managing funding mechanisms and donor relationships, so that unless a civil society advocacy movement exists around nutrition, it is unlikely to be held to account for inputs or outcomes.

iii. Targeting and monitoring One important dimension of this lack of coordination is related to a lack of clear and shared goals among those working on nutrition. Over the period of the NNP (2003-11), the target laid out in the MoH’s planning documents was explained by a high-level policy advisor on nutrition as being ‘the Millennium Development Goal 1’, i.e. to halve the prevalence of underweight – an ambitious goal given the relatively short time period and the fact that there was no agreed national baseline for this target, and growth monitoring data was only available for a small proportion of children. An interviewee from a technical advisory body to the MoH referred to a target for the 2003-11 period of reducing ‘malnutrition’ (metric unspecified) from 94 per cent to 20 per cent. The mandate of the IPHN, the government’s advisory and coordinating body on health-related nutrition interventions, does not include a specific target on malnutrition.

iv. Perceptions of ‘nutrition’ Related to this lack of targets and clear goals, it was hard to identify a common story about the problem or possible solutions, particularly around the central issue of what ‘nutrition’ consisted of. Understandings ranged from caloric intake (with the indicator being the absence of acute malnutrition requiring treatment), through food security (incorporating issues of availability and access), to preventative nutrition interventions such as food fortification and supplementation, and finally behaviour change communications. These related interventions were not explicitly incorporated into the MoH’s understanding of its mainly curative brief. One interviewee from the food security sector commented on the capture and narrowing of the issue of nutrition by the MoH, feeling that this contributed to the invisibility of the problem on the national scale.

Another problem was a deliberate narrowing of the issue by civil society actors. Donors spoke of a prevailing tendency amongst civil society actors in the nutrition sphere – primarily researchers and advocates – to focus on the need for particular interventions, such as breastfeeding or supplementation, over all others and at the expense of the broader picture. They complained that these ideological fault lines led to a scenario where it was impossible to convene people from different perspectives, and impossible to have a broader discussion about cross-sector work. Thus the representation of non-governmental stakeholders was diminished, and their capacity to hold the government to account for nutrition outcomes almost entirely neutralised.

A senior policy advisor on nutrition suggested that this fragmentation of understanding of nutrition, and the consequent fragmentation of policy discussion, was keeping the private sector from playing a meaningful role in policy and interventions. Here, too, the championing of highly specific interests and exclusion of others had led to various scenarios in which the private sector was not able to contribute, one example being the struggle to have ‘plumpy nut’, a therapeutic food for the severely malnourished, approved as safe by the country’s regulators. The private sector did play a role, however, in healthcare provision, with as much as 70 per cent of healthcare being sought from private providers rather than government clinics. However, these private providers, who range from city doctors’ practices to those without formal qualifications in remote and rural areas, were not actors in nutrition policy and were not involved in delivering any interventions – something which might constitute an opening if it were possible to coordinate them around a national goal.

v. Electoral incentives and nutrition

Within the MoH, the main institution charged with nutrition policy, there is a basic disjuncture between its preventative and therapeutic briefs, possibly due to the fact that therapeutic services are more ‘visible’ in terms of policy and public perception. In contrast, the growth monitoring and nutrition promotion activities that are also important, along with supplementation and complementary feeding, are less politically visible on the national or local levels. Many interviewees believed these would be neglected under the new mainstreaming policy, one commenting: ‘effective programmes are invisible and do not reward MPs electorally.’ Another said, ‘people do not see malnutrition. If everyone’s children in the village are stunted, stunting is normal and they do not perceive a problem.’

Thus legislators have not been strongly involved in nutrition, either at the ministerial or the parliamentary levels. At the parliamentary level, the lack of a clear policy message about nutrition decreased the likelihood that it could become an important issue: although MPs commonly distribute food in their constituencies, ‘nutrition’ is seen as a less electorally rewarding issue for them than basic food provision to the poor.

At the highest levels of government, controlling the price of rice was addressed as a sine qua non for electoral survival, with a strong and well-organised policy infrastructure operating under the Agriculture and Food and Disaster Management portfolios rather than a nutrition brief. It is significant that the national food policy was formed under the management of the Ministry of Food and Disaster Management (MFDM) after its high profile success in managing the response to large scale flooding in 1998. In Bangladesh, nutrition is inextricably tied to food availability, which is in turn tied to environmental crises such as flooding. It is also tied to the commodity of rice, which is highly important politically despite its lack of real nutritional value. An analyst interviewed noted that food prices were the main focus of public attention, with rice as the most symbolic food item, so that a government that allows rice prices to rise too far is highly electorally vulnerable.

The MFDM’s status as the main agency for disaster management and the location of the committee that sets the price of rice empowered it to manage the decade-long process of nutrition policy formation since 1998. It also empowered it to work in a cross-sectoral way – although even this was not enough to overcome the drop in support for the formation of nutrition policy that occurred with a changeover of ruling parties in mid-2001, after which it took five years for the policy to pass. The previous party having approved the policy, but still without formal cabinet approval, the new government stalled on the bill for four more years until it was about to leave office, and only then approved it. This focus on the overall availability of key food commodities comes at the expense of a more nuanced discussion of nutrition, so that there is a high level of electoral accountability for food prices and for food access, but not for nutrition outcomes.

b) Vertical articulation

i. Siloed service provision

Vertical coordination in nutrition is strong but siloed. As shown earlier (fig. 2), each ministry is operating programmes that reach a proportion of the population at risk of malnutrition, but two main problems may apply. First, a lack of overlap between vertically operated nutrition-related programs. For example, the Ministry of Women and Children Affairs has several programmes with a strong nutrition element, such as vitamin supplement packages for newborns, or an allowance for lactating mothers, each of which falls under social safety net programming and is needs-based in its targeting. However, this targeting does not relate to targeting of the MoH’s nutrition programmes, and women cannot receive multiple subsidies. MoWCA’s target group for nutrition is now being extended to include conception to five years of age, but given that women cannot receive multiple subsidies, this means that the existing beneficiary population cannot be included. Perhaps it is for this reason that a high-level policymaker at this ministry stated that ‘a national nutrition programme would be too massive to handle – women and children are best served by separate interventions’.

The second problem is over-centralisation of interventions – i.e. restrictive structures for vertical control on the part of ministries. A high-level government interviewee said that all programming decisions resided with high-level staff, so that ministers were involved with procurement, transport and other issues that could be more effectively handled at a lower level of government. District hospital staff must get permission directly from the Minister of Health in order to travel, or to purchase necessary items such as vehicles. This is unlikely to change given that mainstreaming will further centralise control in individual sector ministries. This further centralisation seems unlikely to resolve the practical problems of programme activities around nutrition, where strong control of local authorities by the central bureaucracy has contributed to a culture of impunity around corruption in procurement and inadequate provision at local level.

**ii. Local coordination; local disjunctures**

Meanwhile, at grassroots level, intersectoral coordination is frequently occurring through experience and after years of different sectors working alongside each other, though not by design. An NGO official explained that individual government and NGO workers at community level have come to coordinate because they share basic needs for goods and materials, but that this is not recognised in financial or programming decisions. In the future, nutrition policy mainstreaming will make it imperative for community level and NGO implementers to follow the national framework, but this is dependent on orders from the central government passed down through each ministry involved. Moreover, so far the capacity and funding have not been in place for this to happen. For example, the new policy framework demands that basic nutrition monitoring functions be devolved to health extension workers, but as one of 32 operational packages in their brief, ranging from child immunisation to hygiene education, it seems unlikely that they will be able to find time for child Growth Monitoring and Promotion (GMP), and the accompanying nutrition counselling that renders such an intervention worthwhile (Lancet 2008).

The consensus among interviewees was that local government was not a strong resource for coordination, and often lacked the tools to do the required programming – for example, some of the highest rates of malnutrition are believed to be in urban slums, yet municipal governments have no social safety net portfolio. In contrast, northern areas of the country have formed local committees on nutrition, but are believed to have no stronger nutrition outcomes than southern areas.

The Dhaka City Corporation has a separate health system in which it runs its own clinics, but has no nutrition programme and is not involved in the national program to extend severe malnutrition treatment through community health centres. This is most probably a result of Dhaka’s exponential population growth over the last three decades to its current level of 20 million people, a large proportion of whose housing is informal and who are marginalised in terms of healthcare. National policy has yet to catch up with this situation, which presents a further coordination challenge for senior policymakers.

One former donor, now a researcher, pointed out instances where local and national government clash over policy: first, between MPs and local government, where MPs are unwilling to share power or credit for achievements with local councils. Second, in policy execution where there is tension between the functions of local civil servants and elected representatives, with local civil servants unwilling to work under local government heads (whom they perceive as lower in social status), and instead wanting to work under MPs who have access to contacts and funding through their connections to the central government.

Another issue in the vertical dimension is the involvement of larger and smaller NGOs. The four existing local-level interventions – vitamin A supplementation, school feeding, supplementation for lactating mothers and deworming tablets – are provided by large NGOs such as UNICEF through implementation partners such as BRAC. BRAC was formerly the chief implementing NGO for the BINP, but pulled out due to management issues, notably gaps in programming caused by funding problems (covered in the next section) and now only handles the implementation of BCC programmes.

iii. Political capture With large institutions such as BRAC are largely missing from the implementation landscape, there are numerous smaller proprietary NGOs focusing on the local level. These NGOs, interviewees said, constitute a problem in terms of capture of resources. A high-level advisor on health policy said he believed that capture within government provision structures was 40 per cent, while with NGOs it was only 20 per cent on average – yet with some of these smaller NGOs, the level was more like 80 or 90 per cent. He commented, 'Many survive [due to their NGOs] – they were previously unemployed, now they have a nice car. Many of the donors are happy to work with them.'

In terms of local level political capture, several interviewees across various sectors identified targeting of social protection and other distribution programmes as problematic, and highly subject to local patronage links. The strengths of local Upazila chairmen – their local knowledge and ability to identify needs and distribute nutrition inputs effectively – are also their greatest risk in terms of local capture. In contrast elite political capture, interestingly, was not felt by most of those interviewed to be a serious problem. 'Elite capture is spread out,' a local governance analyst attached to a donor organisation said, 'for example, everyone pays for their BGD [social protection entitlement] card but the revenue goes all over the government, not to one single rent-seeking organisation'.

iv. Political sustainability Given the constant electoral swings between the two main parties, the Awami League (AL) and Bangladesh Nationalist Party (BNP), the issue of political sustainability is central to the success of nutrition mainstreaming. Government and donor representatives were divided on the likelihood of problematic upheavals in nutrition policy in the event of a change of government. The next national election is in 2014, and the only agreement was that if the new system of community clinics could be rolled out and fully established in time, it would be hard for the next government to cancel such a large change in modes of service provision.

It is clear that different programmes are aligned with the two main parties: the initial deployment of community clinics, first started by the AL in 1998, was delayed by a change of administration to the BNP in 2001, then taken up again once the AL was back in power in 2009. A ministerial-level interviewee involved in sectoral activities on nutrition felt that the clinics would become a politically vulnerable item in the same way that children's centres had (another AL programme which was halted under the BNP).

Two positive models of political sustainability exist: free and compulsory girls' education, which was initiated by the BNP in the 1990s up to grade 10, and then adopted by the incoming AL government, and extended to grade 12. 'If a project can show results immediately and become popular it will endure,' one former donor said. Food policy offers a very different model for political sustainability, having remained unchanged across four consecutive shifts in administration. An interviewee from the national food policymaking body said that food and agricultural policy were translated into entitlements and were too risky to change – 'a government may change the name, or 2-5 per cent of the budget, but nothing more'. The most common view was that if local people could come to perceive community clinics as their right before the next election, popular demand would ensure that they survived. ‘Practically, before there was no system’, one high-level health sector advisor said, ‘but we have been able to create peanuts, which are enough. Now there is something, people will demand ... there may be enough demand that the system [of mainstreaming nutrition services through clinics] can be sustained.’

c) Funding mechanisms

Funding mechanisms have tremendous potential for greater coordination both vertically and horizontally to Bangladesh’s nutrition problems. This can be seen from the bilateral discussion and implementation structures which dominate the nutrition policy landscape, with large funders such as the World Bank, DfID and UNICEF wielding significant policy influence in comparison to smaller donors.

Existing direct funding mechanisms under the 2003-11 World Bank SWAp, however present such a management and accounting challenge that they have given rise to what is euphemistically being termed a ‘capacity problem’ in the GoB. The current system is highly complex and requires both significant advance administration on the part of implementation partners and huge accounting capacity within the sector ministries, especially the Ministry of Finance itself. Requests for funding for different elements of national nutrition programming must pass through the World Bank’s Washington D.C.-based accounting structures, and operate on an 18-month contracting period where contracts take four to five months to process. Thus if an implementing organisation does not start its paperwork early, this causes a gap in implementation. A senior accountant within the Ministry of Finance gives an example: ‘last year, the Ministry of Family Planning wanted oral pills, but 32 signatures were needed from DC, and the programme has been delayed for two years.’

In the current situation, proposals must be made by sector ministries to Washington via the Ministry of Finance, and during the approval process the MoF releases the funds in advance of reimbursement so that programming can operate. The money is then transferred into the country’s central bank by the Washington administrators, and may arrive up to two years after the funds have been spent by the relevant programme. Separately there is a pooled fund, also managed by the World Bank, where sector ministries have to contract with all the development partners to receive money for programme implementation.

These complex arrangements have drawbacks for both donors and recipients. They are not user-friendly for the Bangladeshi government, and for the MoF in particular, where the system takes a year to learn, and staff are often transferred and replaced. The system of spending funds before they are officially authorised and transferred, and the long lead time in contracting, results in a higher potential for local-level corruption, since procurement processes often generate duplication of items by different implementation bodies. The system also creates funding gaps where service provision runs on a six-month on, six-month off basis, with NGO staff having to work unpaid to continue implementation with no materials.

The rigidity and delays inherent in the system also raise problems for donors, driving them toward project support and parallel funding and consequent fragmentation of programming. As one government advisor put it, ‘everything is done on soft loans, nothing is free.’ Donors often prefer parallel funding because it gives them greater leverage over the GoB, unlike participating in the pooled fund where their contribution is dwarfed by that of the biggest donors. There have been cases where funding mechanisms have facilitated new processes, as when DfID and USAID offered advance support for policy implementation during the formation of the national food policy (formed by the MDFM and 20 per cent dedicated to nutrition concerns). Here, the offer of funding for coordination activities over five years added leverage to the policymaking process, and, combined with the support of the Prime Minister, allowed it to continue.

The complex and dysfunctional funding system looks set to continue, despite a recent move by the Ministry of Finance to shift toward direct budget support for nutrition, which was also supported by main donors such as the FAO. However, the Ministry of Health reportedly resisted, claiming not to have the capacity to manage budget support. Thus the more complex system has been chosen to support mainstreaming over the 2011-16 budget period.

d) Other factors potentially influencing malnutrition

Given that Bangladesh’s economy is growing at around 6 per cent per year (fig. 3) despite possible slowing due to the global financial crisis, it is possible that the most important factor driving the decrease in malnutrition rates since the 1990s may be increasing incomes.

Figure 3. Bangladesh GDP growth, 1996-2010

![Bangladesh GDP growth, 1996-2010](image)

Source: World Development Indicators (GDP growth)

However, income inequality must be taken into account: is the increase in income reaching the poorest? If not, a rise in food availability and diversity nationally may not translate into access for those locations and groups where malnutrition prevalence is highest. Figure 4 shows contradictory indications on this question: while Bangladesh’s Gini index (where 1 represents perfect inequality of income and 0 perfect equality) rose in the early 1990s and since then has flatlined in the mid range at 0.31, the poverty headcount, based on the national poverty line, has decreased overall since the early 1990s, from nearly 57 per cent to 31.5 per cent. Thus the increase in income can be judged to be reaching some of the poor, but not necessarily all. Given that interviewees said malnutrition was now most prevalent in urban slums and among marginalised and excluded ethnic groups, this may support the idea that overall rural poverty is decreasing but that urban migrants and certain ethnic groups should be seen as the new foci of the malnutrition problem. Again, there is insufficient data available to confirm this hypothesis. One potentially important factor within this scenario of rising income and unevenly falling poverty is remittances, both from Bangladeshis working abroad and from those who migrate within the country to work, often seasonally. Remittance income has risen rapidly since the 1990s to around US$11bn in 2010, but the evidence for how this may affect nutrition is thin. In 2002, the International Organisation for Migration stated that ‘food represents the highest outlay of remittance money’ (IOM 2002). However, there is very sparse evidence as yet on whether remittances contribute to dietary diversification, i.e. whether households are eating better, or simply more. Babatunde and Martinetti (2011) find in their study of Nigerian remittance receiving households that remittance income increases calorie consumption but does not significantly affect dietary quality, micronutrient supply or children’s nutritional status. The key may, however, be nutrition education: a recent review suggests that conditional cash transfers are associated with dietary diversification in a context where nutrition education is occurring (Kabeer, Piza and Taylor, forthcoming 2012). It is therefore reasonable to argue that nutrition education is of potentially huge importance if policymakers wish to make use of remittances’ potential in this area. Implementing NGOs confirmed that poor villages were seeing significant out-migration - up to as much as 90 per cent of working-age men in some cases - but said the number sending back remittances varied according to occupation and other factors to do with their migration experience. Nevertheless, this huge increase in remittance income on a national level suggests that these inflows represent an important resource for improving nutrition outcomes.

V. Relevant findings and preliminary conclusions

a) Findings It is possible that there is a problem of diminishing marginal returns with regard to malnutrition in Bangladesh, where, as one funder said, ‘we have picked the low-hanging fruit ... the next three-per-cent decrease in malnutrition will be much harder to achieve’. Previous success combined with such diminishing returns might explain the current flatlining of progress on the underweight prevalence rate, and the slightly more encouraging dip in stunting – combined with the lack of decrease in wasting prevalence. However, this study demonstrates that there are many of what might be termed ‘low hanging fruit’ available in terms of forming more coherent coordination, financing and implementation strategies, which might well impact on the country’s overall ability to achieve a change in its malnutrition prevalence rates.

i. Converging perceptions, diverging responses Differences of opinion as to the scope and scale of the problem, or of the appropriate responses to it, are present in all sectors: government, donors and civil society (the last in the form of researchers and advocates, since civil society as a whole is still not involved in demanding attention to nutrition). The division between curative and preventive work is also a disjunction: for example, the MOH sees work as curative that UNICEF sees as preventive. For other ministries and official bodies, the problem is perceived as one of intersectoral coordination, while for donors, the problem is perceived primarily as a technical and capacity challenge: given that they have funding and active programmes, they primarily need human resources to operate them.

ii) The politics of nutrition: sectorally divided, vertically fragmented Overall, the picture of nutrition policy and programming in Bangladesh is one of great diversity and some fragmentation, with a lack of coordination between sectors and actors on all levels. This lack of coordination, in turn, relates to differing understandings of nutrition itself, combined with disagreements about and unawareness of the magnitude of the problem, and of the range of interventions relevant to combating it.

The country lacks a clear baseline or target in terms of combating malnutrition, aside from the Millennium Development Goal itself, which specifies a reduction in underweight but must be split up into component parts in order to be operationalised. There is agreement, more or less, about the magnitude of the problem – most agencies involved in nutrition programming are aware that the national malnutrition rate stands around 40 per cent – but little agreement as to what results might be expected from an effective response by 2015, or who should coordinate that response overall. Bangladesh has chosen to be an ‘early riser’ in the SUN initiative, which may make new options available for policy and coordination (UN 2011). Furthermore, this system and its attendant lack of coherent targets has led to a situation where nutrition success is measured by the inputs and outputs of individual donor-sponsored programmes, which engage primarily with food security and do not add up to a coherent vision of nutrition needs and outcomes. Without strong central leadership from the GoB driven by accountability for nutrition outcomes to its own people, it is difficult to see where the incentives for change may come from, since donors are highly incentivised individually to run successful programmes that contribute to combating malnutrition, but much less incentivised to push for real coordination and vision within the government. Electoral politics play an important role in discouraging this kind of governmental leadership, as without a strong civil society push for the right to adequate nutrition, policy in this area almost inevitably becomes seen as a partisan issue. All government-sponsored interventions must be considered potentially vulnerable to changes in the governing party, which offers a considerable incentive to focus on a single structural goal (in this case community clinics) in coordination with a single sectoral donor (the WB) and to allow other interventions to occur through fragmented but independent programming by donors.

iii) Siloed finances reinforce fragmentation Although, as noted above, fragmentation may have some benefits in terms of sustainability across administrations, it has led to an untenable situation in terms of funding. While individual donor programmes are funded directly, in contrast larger-scale programmes run through sector ministries are dependent on an intricate system of financing that is almost impossible for implementers to manage. This system leads to consistent gaps in funding which make it difficult for community-level implementation to function. This reinforces fragmentation in programming, as the most reliable way to achieve demonstrable inputs and outputs (and to be accountable to donors’ own governments) is to fund independently. Pooled funds, which offer greater potential for coordination, thus present donors with accountability problems, as they are distributed through the same overly-complex system as sectoral funding.

b) Entry points for intervention

i. Responsibility for coordination A high-level Health Ministry official interviewed for this research stated that ‘nutrition is a multisectoral issue, but this does not mean we always have to work together’. This is revealing in two ways. First, the MoH is not treating coordination as a central item in its nutrition portfolio. This may merely signify realism, since it clearly lacks the authority, the incentive, or both to bring together the relevant high-level stakeholders around nutrition. But second, this statement makes the valid point that line ministries can work on nutrition without constant oversight by one in particular. If it were possible to resolve the lack of a definition of, and target for, nutrition, and workable mechanisms for discussion making it possible for donors’ priorities to be aligned with the government’s, the need for extensive coordination would be less.

Bangladesh illustrates the gap between coordinating and merely maintaining relationships. The country has a nutrition policy, but implementation relies on the activation of several linkages that are currently missing: between line ministries; between these ministries and donors as a group; between different levels of government and between implementing bodies at local level.

Overall, the GoB and nutrition donors seem involved in a mutually reinforcing feedback loop regarding the responsibility to coordinate. As long as the GoB does not take the initiative, there is no opportunity for donors to enforce coordination between ministries and other bodies. Equally, as long as donors work within the current system, there is no incentive for the GoB to disrupt the status quo and force its nutrition stakeholders into new configurations.

This fragmentation also gives rise to conceptual and functional overlap between food production, food security and nutrition, for donors as much as for government. This overlap incentivises the GoB to create clarity by defining ‘nutrition’ as a set of curative and preventive activities that take place under the auspices of the MoH, which keeps natural partner institutions such as the MoA at a distance both programmatically and in terms of discussion.

ii. Siloed funding further decreases incentives to cooperate

Complex funding systems form another element of this feedback loop. Although these are designed for maximum accountability on the part of the GoB, they mean that government and implementing partners are burdened with procedures to keep current nutrition programming active and on track – an effort that is enough to eclipse the potential for a unified vision and targets. This type of accountability also causes problems with monitoring, by making program data a way to keep funding flowing rather than a benchmark for progress, so that much information flows through individual programmes to donors rather than converging toward a central goal.

The GoB has requested to continue this highly complex funding mechanism over the next five years, rather than take on an increased proportion of direct support. Nevertheless, numerous other mechanisms, offering varying degrees of control to the GoB, were put forward by the MoF and were considered by government and donors. Developing alternate funding streams to test the feasibility of these simpler models might lead to the possibility of change in this area, as long as it does not further burden the already full agendas of the MoF. Equally, exploring different funding mechanisms such as pooled funds among bilateral and multilateral donors that are not run through Washington, might offer opportunities for more coordinated programming and a broader vision. In turn, this might enable donors to create programmes with greater size and coverage that gain enough momentum to make them sustainable across national elections.

This situation of fragmentation does not allow for the building of a governmental constituency for nutrition: experienced administrators such as those from the NNP have been entirely disbanded as policy and implementation structures have been changed or abandoned; research organisations are concentrated around agriculture and are insufficiently involved in broader policy and implementation; multilateral and bilateral donors are pursuing their own programmes and the GoB is not drawing their expertise, monitoring capacity or resources together around its agenda. The last issue is largely due to the politics generated by funding mechanisms: the issues surrounding direct budget support for a nutrition agenda seem to be both the reason such an agenda is not fully formed, and the reason it cannot be discussed on equal terms between government and donors.

iii. Aligning nutrition with electoral interests and the public agenda

The issue of electoral interests and public support for combating nutrition is partly one of understanding. Nutrition could join education and immunisation as a cross-party policy issue, if a stronger programmatic focus is achieved. Leadership around recognising and publicising the scale of the problem, its main locations and socioeconomic dimensions would go a long way toward facilitating a meaningful and evidence-based dialogue between different institutions. One way in which it could be addressed would be by including orienting the various social safety nets run by different ministries more explicitly toward issues of nutrition, since it is part of several – such as school feeding programs and pro-poor service packages – already. Similarly, if geographic poverty data were used to guide nutrition interventions (in the absence of clear and universally accepted data on malnutrition) this would have the added benefit of bringing nutrition together with poverty issues as a national concern.

Coordinating mechanisms such as SUN cannot be relied upon to tackle this problem of national-level perceptions and the will to act, particularly in situations where a country is aid-dependent and donors can drive policy change and implementation without having to engage with public perceptions. Monitoring and evaluation cannot be stressed enough as an important factor in resolving some of this disjuncture between government, civil society and donors, since independent surveys and baselines are being conducted in place of seeking agreement on the data, and could well reinforce differing views on the problem and the interventions needed.

There are several potential models for raising the profile and perceived importance of nutrition. First, attaching the monitoring and communications elements of the nutrition strategy to larger poverty programmes or institutions, as has been done in Latin American poverty reduction programmes. This could be accomplished by re-establishing or deepening relationships with BRAC and other important NGOs who already perform large-scale community-level service provision. Second, folding nutrition issues into the discussion and implementation mechanisms that exist around food supply and prices, which are well coordinated and involve many of the stakeholders missing from the coordination scenario around nutrition. Third, exploring grassroots-level, potentially self-sustaining mechanisms for the improvement of nutrition consciousness such as influencing remittance spending with nutrition education. Fourth, strong monitoring and evaluation systems that provide meaningful inter-DHS data sources and make it possible for civil society to hold government and donors accountable for nutrition outcomes rather than inputs.

This list of suggestions does not include changing the forum for high-level discussion, or tackling the most immediate obstacles in terms of the financing or operationalisation of interventions. The first task may instead be to find the will to make nutrition policy and implementation real and measurable: this must be done by finding ways to insert nutrition prominently into the political agenda of government and institutional stakeholders, so that the resulting pressure generates greater accountability and attention for nutrition outcomes. If this can be achieved, it may be easier to generate and sustain the will to address many of the obstacles to effective action identified here. VI. Bibliography

Babatunde, R.O., Martinetti, E.C. (2011) 'Impacts of migrant remittances on food security and nutrition of Farming Households in Kwara State, Nigeria'. Contributed paper for the International Conference: Shocks in Developing Countries. June 30 – July 1, 2011, Paris, France.

BDHS (2007). Bangladesh Demographic and Health Survey 2007. Dhaka, Bangladesh and Calverton, Maryland, USA: National Institute of Population Research and Training, Mitra and Associates, and Macro International.

Bhutta ZA, Ahmed T, Black RE, Cousens S, Dewey K, Giugliani E, Haider BA, Kirkwood B, Morris SS, Sachdev HPS and Shekar M (2008) 'What works? Interventions for maternal and child undernutrition and survival'. The Lancet 371(9610):417-40.

Global Health Initiative (2011) Bangladesh strategy. Available at: www.ghi.gov/country/bangladesh/documents/159681.htm

IOM (2002) ‘A study on remittance inflows and utilization’, Dhaka: International Organization for Migration.

Bryce, J, Coitinho, D, Darnton-Hill, I, Pelletier, D, Pinstrup-Andersen, P (2008) ‘Maternal and child undernutrition: effective action at national level’ Lancet 2008: 371: 510–26.

Kabeer, N, Piza, C, Taylor, L (forthcoming), Systematic Review of the Economic Effects of Conditional Cash Transfers. Journal of Development Effectiveness, 2011.

Mannan, M. (2003) ‘An evaluation of the national food and nutrition policy of Bangladesh’, Food and Nutrition Bulletin, 24:2.

Shahabuddin, Q (2010) 'The Right to Food: Bangladesh Perspectives'. The Bangladesh Development Studies Vol. XXXIII, March-June 2010, Nos. 1 & 2

UN (2011) ‘Progress Report from countries and their partners in the Movement to Scale Up Nutrition’. Geneva: United Nations

UNICEF (2008) Child and Maternal Nutrition in Bangladesh: key statistics. Available at: www.unicef.org/bangladesh/Child_and_Maternal_Nutrition(1).pdf

World Bank (2005) The Bangladesh Integrated Nutrition Project: Effectiveness and Lessons. Available at: www.unscn.org/en/resource_portal/index.php?themes=153&resource=287

WHO (2009) ‘Landscape analysis on countries’ readiness to accelerate action in nutrition’. SCN News, 37.

## Appendix: list of interviewees

### Table 1. Interviewees for Bangladesh country study

| Executive / Legislative | Coordination/Research | Donor/NGO | |-------------------------|-----------------------|-----------| | Min. Health and Family Welfare | Institute for Public Health and Nutrition | World Bank | | Min. of Women and Children Affairs | Bangladesh Agricultural Research Council | UNICEF | | Min. Food and Disaster Management | International Centre for Diarrhoeal Diseases Research, Bangladesh | Food and Agriculture Organization | | PM’s office | Bangladesh National Nutrition Council | BRAC | | Min. of Finance | Bangladesh Applied Nutrition Human Resource Development Board | Dept. for International Development, UK | | Member of Parliament | | | | Dhaka City Corporation | | | | National Nutrition Programme | | |